On 11 March 2011, an earthquake with a magnitude of 9.0 on the Richter scale struck off the coast of Japan, triggering destructive tsunami waves of up to 40 metres high that swept over the north-eastern coast of the country. It was the most powerful earthquake known in the country's history. As of July 2011, 15 585 people were confirmed dead, 5070 missing and 5694 injured.1 Furthermore, the earthquake and tsunami led to explosions and release of radioactive materials at the Fukushima Daiichi nuclear power station.

From its experience of massive earthquakes (Kobe in 1995 and Niigata in 2004 and 2007), Japan was prepared to respond quickly.2 The Japanese government set up the emergency disaster response headquarters to initiate disaster relief immediately and, within 24 hours, 178 disaster medical assistance teams were dispatched to the disaster zone. In addition, the Japanese Medical Association sent teams, each comprising one doctor, two nurses and a health staff member, and the Japanese Association of Psychiatric Hospitals dispatched psychiatric staff through these teams.

On day two after the disaster struck, the Japanese Society for Psychiatry and Neurology set up a disaster response committee, together with other academic, clinical and medical organizations. On day three, the National Center of Neurology and Psychiatry launched a web site to provide guidelines and manuals for professionals.

Within one week, the Ministry of Heath, Labour and Welfare had organized mental care teams, which provided standard care to people who already had mental disorders and to those who needed care as a result of the disaster including health workers.

Mental health services were severely disrupted. Even before the disaster, community care in particular was not available to many people in need. Initially the priorities were: (i) to transfer existing psychiatric patients to hospitals outside the affected area, and (ii) to re-establish and strengthen mental health services in the disaster zone.

This disaster will likely increase the long-term incidence of mental disorder and distress.3 Many people have lost their families, their work, their property and their entire community. Such life stressors are an established risk factor for depression. Many of the bodies of the deceased have not been found yet so people may have difficulties finishing the mourning process because, culturally, Japanese people have a strong attachment to the remains of their loved ones. An increase in isolated deaths among the elderly is also expected due to the breakdown in community support networks. In addition, the anxiety surrounding the nuclear disaster will further increase the need for psychosocial care, not only in the disasteraffected area but in all of eastern Japan, including Tokyo.

The increased demand and interest in mental health by the public, including the media and politicians, provide opportunities for improvements. In recent years, countries including Indonesia and Sri Lanka have established sustainable community mental health systems in disaster areas.4 , 5 While Japan has an established mental health system, there is great room for improvement in community mental health especially in rural areas. In the existing situation, it would have been impossible for psychiatric clinics and hospitals to provide care to such large numbers of people.

So, what is needed to make the mental health system sustainable? First, we need to strengthen the available community mental health services, with the back-up of specialist care (i.e. hospitals and clinics). Psychiatrists, psychiatric nurses, social workers and psychologists in the affected area have been working to their full capacity supported by teams dispatched from other parts of the country, but this is not sustainable. Therefore, it is important to strengthen the capacity of the existing local hospitals and clinics by providing mental health training and supervision to community health workers.

Second, assuming that many people will not seek help at mental health facilities, these services should be integrated into general health services with back-up by specialized mental health services.

Third, we need to establish a network of self-help groups for survivors of disasters because community and personal support is important for sharing information about self-care and psychological first aid.

During this process, it is important to consider local culture and community. The traditional coping mechanism in Japan is not to express grief or anger, but to endure, tolerate and to move on, quietly supporting one another. This could explain why, amid this devastation, these communities have succeeded in maintaining social stability. After each disaster, people put the trauma to the back of their minds and re-establish their communities.